Anorexia Nervosa is one of the psychiatric illnesses related to eating most common in females (Bulik et al., 2006) and young people (Bergh, Brodin, Lindberg, & Södersten, 2002). The client for this study is a 13 years old girl who lives with her single mother and has no siblings. The mother of Annette, the client, started to observe changes in her behavior regarding eating when she was no longer taking the breakfasts and eating on time; therefore, she was clinically assessed because anorexia nervosa patients also save themselves and lead to weight loss (Schmidt & Treasure, 2006). From a cognitive behavioral therapy perspective, cognitive behavioral therapy is a treatment for the cases of anorexia nervosa patients (Christopher G. Fairburn et al., 2013). Cognitive behavioral therapy techniques are aimed at reducing the maladaptive thought and presumptions of the clients (Beck, 2011). Annette said that her change in behavior is because her image of being fat is disturbing her, and her aim of becoming a cheerleader is not going to work until she has lost the weight so anorectic systems are also related to a physical presence of a person (Schmidt & Treasure, 2006).
Body image is a complex phenomenon and has several ideal setups, and these images are constructed interpersonally with friends and cultural expectations (Cash, 2012), and as a result, Annette has been trying to look slim and starve herself. There is a lot of emphasis on body image in a western society where fat people have issues with fitting in the culture, and because of that image, Annette was starving herself to fit in the body image to fit in the real image of cool and stylish (Cash, 2012). Self-perception is the way in which a person internalizes physical appearance as mental appearance, and in the case of the client, she thinks her physical image is not really the real portrayal of herself (Cash, 2012). People with anorexia tend to isolate themselves and focus on losing weight with the concept that losing weight will decrease their distress and being slim with social acceptance (Garner & Bemis, 1982). Annette’s mother tried to motivate her to involve in social conditions by understanding her situation as for anorexics, the attention and support from their parents become a positive reinforcement (Garner & Bemis, 1982). According to cognitive theory, aberrant thinking can result in inexorably and predictably, as Annette was thinking that being thin would give her a place in the street dancers group, and she would ultimately have a boyfriend (Garner & Bemis, 1982). According to Cognitive behavioral therapy (CBT), women who have eating disorders such as anorexia nervosa perceive their body size as more massive and therefore have a negative evaluation of their looks. Annette thinks that being overweight, she is not attractive and thus cannot approach boys, and losing weight would give her fame (Cash, 2012).
Psychodynamic therapy is also essential to understanding the underlying behaviors and desires which lead to action, such as the desire of Annette to become slim in one way or the other (Colarusso & Nemiroff, 2013). Psychodynamic therapy provides a more in-depth understanding of the development, interactions with other people, physical state, and mental conflict that an individual goes through (Colarusso & Nemiroff, 2013). Psychodynamic therapy works on the symptoms and relationship patterns of those individuals with other people, and those who have anorexia tend to view depending on someone as a sign of weakness (McIntosh et al., 2005). When the primary focus is on losing weight or maintaining the body image, then the concept is self-sufficient as Annette thinks that her mother is trying to control her life, and she said this during her session with the school psychologist (McIntosh et al., 2005). She views that if her mother stops managing her life and lets her do whatever she wants to, then it will be better for both of them, and people who have anorexia tend to believe that their primary aim is essential and other relations are secondary (Johnson, 1991).
The primary purpose of psychodynamic therapy is to understand how an individual’s context plays a role in understanding his relationships and functioning (Guntrip, 1995). To realize one’s behavior in the context of a person’s behavior functioning of human nature and how the actions disturb the social life of the individual and the outlook to life (Guntrip, 1995). The way Annette’s life was troubled and how her relationships with other people were unhealthy shows that her behavior and her unconscious desires were impacting her socialization, and rigid limitations of food can affect health (Colarusso & Nemiroff, 2013). People tend to have difficulties in getting into therapies and consider that their behavior is not an issue and because of this, they lack maintaining their relationships with other people (Sansone, Levitt, & Sansone, 2005). For example, Annette has her ultimate aim to attain the attention she needs. Therefore, she has maintained a world isolated inside herself and anything that is being said to her even for her benefit, so she thinks every other person is controlling her, and this is disturbing her behavior (Sansone et al., 2005). The psychodynamic context therapy focuses on the individual just the way her therapy session was solely focused on her and her fantasies and disturbances connected to her eating behavior (MINUCHIN, Rosman, Baker, & Minuchin, 2009). Because of lack of interaction with her mother, she was not able to try out how she could lose weight, like intentional vomiting, and that void is not filled by communication (MINUCHIN et al., 2009).
Both of the frameworks chosen to explain Annette’s health are used widely to describe eating disorders, and in both therapies, there are several steps to analyze the situation of the patients or the clients (Poulsen et al., 2014). For example, in the initial phase of the psychodynamic therapy process, patients tend to be defensive, detached, and exhaustive, as it was observed in the case of Annette when she thought she did not need therapy session and was reluctant to provide any information (Sansone et al., 2005). In anorexia, the symptoms are based on over-expectations and over-valued ideas about one’s self, body shape, and weight (Schmidt & Treasure, 2006). The second phase of the treatment is to understand the cognitive-behavioral therapy of the person instead of letting them know that their behavior is not right, and in the case of Annette, if the psychologist had directly criticized her, then it would have led to more negativity (Butler, Chapman, Forman, & Beck, 2006).
Cognitive behavioral therapy is proven to work for patients with eating disorders and helps in developing and maintaining the relationship with the client (Poulsen et al., 2014). Anorexia patients need the help of therapists to build a diet that is helpful for their daily dietary intake (C. G. Fairburn & Brownell, 2005). Cognitive behavioral therapy is both cognitive and behavioral therapy as it undertakes both emotional and behavioral concerns. The treatment provided by a psychologist to Annette was comprised of discussion about what she thinks, her behaviors, her relations with her mother, and other aspects which are impacting her behavior (Courtois, Ford, Herman, & van der Kolk, 2013). Whereas the therapy of psychodynamic is emotion-based, and cognition understands the underlying and asks questions that make the patient think about the concern rationally (Sansone et al., 2005). The psychodynamic approach is focused on the factors which contribute to the life of the patients and their risky behaviors, as in the case of the current patient and her peers, her understanding that being slim would get her into street dancer groups and the factors which are promoting the anxious behavior in her (Zipfel et al., 2014).
Cognitive behavior therapy is essential as it provides the understanding to the patient of their behavior and also to the therapist that their work has been implemented for the betterment of their client as the therapy can be recommended the Annette as she has been thinking about fitting into the society (Christopher G. Fairburn et al., 2013). Cognitive behavioral therapy is one of the leading evidence-based treatments for eating-related disorders such as anorexia, and it stresses upon the importance of thought and actions at the same time as in the client’s case, thoughts of being slim and fitting in society were leading to her less eating, intentional vomiting and misinterpreting her mother’s behavior as control (“Cognitive Behavioral Therapy,” 2015). There are three phases to the therapy, and the first one is the behavioral phase in this phase, the psychologist will work with the patient to manage the feelings and actions which are developed in a reaction as Annette and her psychologist have a discussion about her feeling to attract boys, be a part of cheerleaders and how her mother’s behavior was discussed (“Cognitive Behavioral Therapy,” 2015).
The second phase is the cognitive restructuring phase, where the therapist tries to trigger the patient about their behavior and then probe them in a way that is challenging to their logic and intellect, such as asking about the importance of losing weight and how it will impact the life (Sansone et al., 2005). During this phase, psychologist tends to address the concerns related to body image, peer pressure, socialization, and relationship with the patient (Schmidt & Treasure, 2006). The third phase of this therapy is to help the individual maintain the behavior and have a positive outlook to the idea that things will work best even when they do not starve themselves (“Cognitive Behavioral Therapy,” 2015). Many people with anorexia nervosa have difficulties in attaining any kind of help and especially when the support requires putting the fear of body imaging in front of a person who is not known to you, and these people are not willing to change their behavior (Health (the UK, 2004). The response of Annette was similar where she thought that her mother should let her do whatever she is doing and should not interfere in her life as she is grown up, and she was in denial that this could put her life at risk (Health (the UK, 2004). In other words, cognitive behavioral therapy has a primary focus on negative thoughts which are associated with eating, weight, and body shape, and this therapy would best fit the situation of the client of this research (Wild et al., 2009). People often go mood swings, have low self-esteem, and idealization of being a female and having a female body which is perpetuated in society (C. G. Fairburn, 2008).
Psychodynamic therapy is a different approach to handling people with anorexia nervosa as it views that people have conscious and unconscious desires which can lead to deviant behavior (Zipfel et al., 2014). Focal psychodynamic therapy was devised as a standard version of time-oriented psychodynamic psychotherapy, and the recommended therapy for Annette’s case is focal psychodynamic psychotherapy because the treatment which is time-oriented can really impact understanding the unconscious conflicts of mind and body that are resulting in the disorder which is evident that her battle is her thought the being slim is better and she is fat in real (Wild et al., 2009). In the first phase of psychodynamic treatment, patients will be reluctant to open up as they will be undergoing several emotional feelings as a result of starvation, overthinking, and finding ways to make things work (Sansone et al., 2005) such as Annette was having a hard time understanding that not eating would lead to other health issues but instead she was in the belief that her mother is controlling her and there was no need of therapy. In the second phase of psychodynamic therapy, the factors which are contributing to the behavior are explored and discussed to find out alternative strategies for coping (Sansone et al., 2005). According to therapists, the contributing factors are what result from a rigid approach to fit into the ideal image of society (Sansone et al., 2005). The last phase of this therapy is reconnection because those who are undergoing therapies or treatment might be feeling left out, so it is essential to let them merge in society and help them reconnect (Sansone et al., 2005). Behavioral therapy looks at what people are doing and how they are doing, but psychodynamic theory looks at why they are doing it, and it is viewed that behavior is the result of previous and current situations (MINUCHIN et al., 2009).
Several clinical research and randomized trials have been carried out to treat anorexia nervosa with cognitive behavioral therapy and psychodynamic therapies. For example, the Anorexia Nervosa Treatment of OutPatients (ANTOP) study was carried out in Germany (Zipfel et al., 2014). In this study, patients from 10 different universities were enrolled in 10 monthly treatment programs, focal psychodynamic (FPT) and cognitive behavioral therapy (CBT), and a combined group, and it was found that cognitive behavioral therapy was effective in improvement in eating disorders and quick weight gain among patients (Zipfel et al., 2014). Another study was carried out to explore the efficacy of focal psychodynamic (FPT) and cognitive behavioral therapy (CBT) and a control group in treating anorexia nervosa (Wild et al., 2009). In another randomized controlled trial, both psychodynamic therapy and cognitive behavioral therapy are proven to be effective in treating social anxiety disorders, and this indicates that it can be useful in treating anorexia (Leichsenring et al., 2013). A study on UK-Italy patients was carried out to explore the impact of enhanced cognitive behavioral therapy on patients, and 99 patients were enrolled in the treatment (Christopher G. Fairburn et al., 2013). 40 sessions were provided to the participants over the period of 40 weeks, and it was concluded that enhanced cognitive behavioral therapy could be useful in treating anorexia patients (Christopher G. Fairburn et al., 2013). As anorexia nervosa is more common in women, so a study was carried out to understand the efficacy of cognitive behavioral therapy, interpersonal therapies, and supportive therapies, but no significant difference was found out between the three treatments (Carter et al., 2011). At the same time, other studies concluded that cognitive behavioral therapy is effective for patient with anorexia nervosa (Touyz et al., 2013). However, more studies are required to compare the efficacy of both the proposed treatment with anorexia nervosa and how effective these strategies be for young children or teenagers.